In response to the global rise in obesity, bariatric surgery has become
increasingly more popular and successful. As a result, the demand for
body contouring following massive weight loss is rapidly growing.
Although bariatric procedures may produce impressive weight loss, people
who achieve massive weight loss are often unhappy with the hanging folds
of skin and subcutaneous tissue that remain. This review examines the
nature of the post-bariatric deformity in each body region and briefly
reviews common approaches to their treatment.

As we enter the 21st century, a new health
crisis has dawned upon affluent western societies, the plague of
obesity. In the United States, the situation is particularly acute with
recent estimates showing that nearly 65% of adult Americans (127
million) are over their ideal body weight, 30% (48 million) are obese
[Body mass index (BMI) ≥
30], and nearly 5% (9 million) are morbidly or severely obese (BMI
≥
40)[1]. Further, the obesity epidemic has expanded globally,
with approximately one-fifth of the one billion overweight or obese
people in the world being Chinese[2]. Although the ultimate
impact of mild obesity on survival has recently been challenged, there
is no doubt that morbid or severe obesity is detrimental to both the
physical and psychological well being of the afflicted patient[3,4].
Morbidly obese patients have often reached a point of no return in which
they are too large and physically unable to exercise.

With some exceptions, the feed-forward cycle of weight
gain in the morbidly obese can be interrupted only by physically
restricting oral intake. This surgical subspecialty, known as bariatric
surgery, has exploded in popularity in the last decade largely because
of improved outcomes, enhanced patient safety and superior techniques
and devices[5,6]. Although early bariatric procedures
produced impressive weight loss, they also resulted in significant
morbidity both initially because of wound healing problems and
anastomotic leakage, and ultimately as a result of their malabsorptive
effects[7]. Modern laparascopic surgical approaches have
minimized wound healing morbidity, while the improvement of more
restrictive procedures, such as the minimally invasive LAP-Band®,
have made weight loss surgery in morbidly obese patients a reliable and
relatively safe procedure[8-12]. According to the most recent
available data, approximately 170 000 bariatric surgeries were performed
in the United States in 2005[13].

However, for the morbidly obese patient, the massive
weight loss that follows successful bariatric surgery is only the first
step in the process[14]. After massive weight loss, patients
are left “deflated”. The excess skin that hangs from the torso, abdomen
and extremities is not only extremely unsightly, but can be painful and
susceptible to recurrent intertriginous infections[15,16]. In
order for these patients to complete their transformation to a formerly
morbidly obese patient, a plastic surgeon must address the deformities
resulting from the massive weight loss[17].

This type of extreme body contouring has grown
concomitantly with the popularity of bariatric surgery, with 55 927
procedures performed in 2004[18]. More than just excising
excess skin and subcutaneous tissue, post-bariatric body contouring
requires unique insights into the nature of the post-bariatric
deformities[19]. In addition, there must be an appreciation
of the fact that massive weight loss patients, because they are often
relatively malnourished or anemic, constitute a distinct surgical cohort
that must be carefully evaluated pre-operatively[20,21]. In
the following sections, we will examine the nature of the post-bariatric
deformity in each body region and briefly review common approaches to
their treatment.

TORSO/ABDOMEN

In formulating a strategic approach to the massive weight
loss patient, the abdomen is usually the first body territory addressed.
The appropriate surgical intervention depends upon the amount and
distribution of excess skin and subcutaneous tissue as well as the
degree of abdominal wall laxity/integrity. In general, as the amount of
weight loss increases, so does the aggressiveness of the surgical
intervention.

For skin excess limited to the anterior abdomen, as might
occur after moderate weight loss or pregnancy, a traditional
abdominoplasty will suffice. In this procedure, the skin and
subcutaneous tissue between the umbilicus and pubis is excised in an
elliptical pattern, leaving a scar concealed within the underwear/bikini
line[22]. Since there is usually an associated abdominal wall
laxity, prior to closing the incision, the anterior abdominal fascia is
plicated, with particular emphasis on re-creation of an appropriate
waist in females[23] (Figure 1A-D).

In some weight loss patients, the resulting abdominal
pannus consisting of loose hanging skin and subcutaneous tissue can be
the source of significant discomfort, recurrent infection and difficulty
with personal hygiene[15]. A simple elliptical excision of
the pannus, which can weigh 25 kg or more, can provide immediate relief
of the aforementioned symptoms, with minimal morbidity[24].
In addition, a panniculectomy is often the only post weight loss surgery
that may be covered by a third party payer[25] (Figure 2A-D).

In most massive weight loss patients, however, the excess
skin and subcutaneous tissue is not confined solely to the anterior
abdomen[26,27]. In order to excise this “cone-like”
circumferential excess, a circumferential excision or “belt lipectomy”
is required[28,29]. The amount of tissue removed is tailored
to the individual patient’s needs. An optimal excision will not only
tighten and flatten the lower abdomen but will also give a beneficial
lift to the buttocks, mons pubis and lateral thighs[29]
(Figure 3A-D).

In some patients (usually those with the most significant
excess), the circumferential excision alone is not sufficient to address
the horizontal dimension of the excess tissue. In these patients, an
anterior ellipse or fleur-de-lis pattern of excision is required[30,31].
For patients who have had previous “open” bariatric surgery (and
therefore already have a vertical midline scar), the additional scar
burden is minimal. Even for patients without a pre-existing midline
scar, the trade-off for optimal abdominal contour is usually acceptable.

Massive weight loss patients undergoing abdominal
contouring procedures often have associated abdominal hernias which are
not always evident on pre-operative physical exam[32,33]. The
surgeon should be prepared to repair these in the course of the
abdominal contouring. General complications of abdominal contouring
include skin necrosis, persistent parasthesias of the abdominal wall,
seroma, infection and wound dehiscence[16,34-36]. Patients
are encouraged to refrain from smoking for at least 3 wk prior to
surgery, as tobacco use has been shown to significantly increase the
morbidity of body contouring procedures[37].

UPPER TORSO/BREAST

Following massive weight loss, in both males and females,
excess rolls (sometimes three or more per side) of skin and subcutaneous
tissue remain. Because of firm underlying fascial attachments, though
these may be improved somewhat by belt lipectomy[29,38], they
can only be completely ablated by direct excision[26].
Usually, the deformity caused by these folds is significant enough that
patients are willing to trade a horizontal scar across the upper back
(hidden in the bra line in females). Furthermore, in women this excess
tissue may be transferred anteriorly and used for autologous breast
augmentation (see breast discussion below)[39,40].

The major deformity of the breast after massive weight
loss in both men and women is ptosis or sagging of the breast which
leaves the nipple areola complex (NAC) below its appropriate anatomic
position. In males, the aim is to excise the excess skin and
subcutaneous tissue while maintaining a flat breast profile[41].
Various patterns of excision exist to achieve this goal. In extreme
cases where the NAC must be moved a long distance superiorly (more
commonly in females), it can be removed and replaced as a full thickness
skin graft[42]. Patients must be warned that this will cause
the NAC to become insensate and may lead to de-pigmentation[43].

Although the NAC can be returned to its normal anatomic
position by various means (at the level of the inframammary fold for
women), a major challenge in female weight loss patients is recreation
of breast fullness and projection. In most cases of massive weight loss,
women are left with deflated empty “pancake” breasts. For female
patients, the goal is to excise excess breast envelope skin while
preserving as much volume as possible.

For most massive weight loss patients, satisfactory
volume and projection can only be achieved with breast implants placed
in combination with a breast lifting skin excision or mastopexy[19,32,39,44]
(Figure 4A-D). The choice of implant used for breast augmentation
is currently limited to saline-filled, silicone-shelled devices or (for
surgeons involved in certain manufacturer study protocols)
silicone-filled, silicone-shelled devices (since 1992 the Food and Drug
Administration (FDA) has banned the routine use of silicone-filled
implants in the United States, although they remain largely the implants
of choice in Europe and the rest of the world and are available to a
handful of surgeons in the United States who are part of ongoing
clinical trials concerning their use).

The most common complication of these devices (regardless
of the implant filler material used) is capsular contracture, in which
excessive fibrous scar tissue forms around the implant leading to
firmness, distortion of the implant and pain[45,46]. Implant
removal or revision of excessive scar tissue may be required in 15%-35%
of cases[46,47]. Other known but less frequent complications
of breast implants are infection, malposition and rupture[45].
Breast implants have not been shown to cause autoimmune disorders[48,49]
or increase the risk of (delayed detection) of breast cancer, although
special mammographic views may be required[50-52].

In some patients, autologous volume augmentation can be
achieved by recruiting local folds of tissue that might be otherwise
excised in the course of body contouring. Most commonly the excess folds
of the upper lateral chest or back tissue are de-epithelialized and
rotated anteriorly into the breast[39,40]. Other surgeons
utilize excess tissue on the upper anterior abdomen from a “reverse
abdominoplasty”. Common complications of breast lift with or without
autologous augmentation are hematoma, infection, seroma and changes in
NAC appearance and sensitivity (although many massive weight loss
patients have little or no NAC sensitivity pre-operatively)[53-55].
In rare instances, the NAC may be partially or totally lost secondary to
ischemic changes caused by surgery and patients should be fully informed
pre-operatively[56] of this unfortunate possibility.

EXTREMITIES

Contour deformities of the extremities after massive
weight loss can be quite significant. Large amounts of excess skin
draped from the proximal half of the arm gives the appearance of a “bat
wing”, while excess skin hanging from the thigh is unsightly and
prevents patients from wearing bathing suits and shorts[19].
The unsightly appearance of their extremities will often prompt patients
to wear long sleeves and pants at all times. To correct these
deformities, the excess tissue must be directly excised. The pattern of
excision used is similar for both the arms and the legs, since the
deformity is essentially the same (a circumferential excess)[26,57,58].

For patients with a mild excess of tissue, the incision
can usually be hidden in either the axilla (for a brachioplasty or arm
lift)[59] or the groin (for a thigh lift)[60-62]
using an elliptical pattern of excision perpendicular to the long axis
of the extremity. This type of excision (“mini” brachioplasty or thigh
lift) is usually insufficient to correct the amount of excess skin
present in most massive weight loss patients[63].

For more significant deformities, an ellipse parallel to
the longitudinal axis of the extremity is utilized, with or without the
aforementioned perpendicular ellipse[58] (Figure 5A-D).
Although this approach can provide remarkable improvement, brachioplasty
scars are long and tend to hypertrophy[64,65]. Furthermore,
contractures across the axilla may occur despite use of “z-plasty”
designs. For brachioplasty, the longitudinal scar is best placed along
the medial surface of the upper arm where it is not visible while the
patient’s arms are at rest[32,66,67]. Similarly, for thigh
lifts a scar is best placed medially along the thigh, although some
surgeons advocate use of an anteriorly or laterally based excision[62,68,69].
Patients must be thoroughly counseled regarding the inevitable scars as
well as other common complications, such as persistent edema,
parasthesias and dysesthesias as well as delayed wound healing,
particularly in the groin area[62].

SUCTION-ASSISTED LIPECTOMY (LIPOSUCTION, SAL)

Although some patients may experience an evenly
distributed massive weight loss resulting in a relatively thin layer of
subcutaneous tissue throughout their body, for most patient this is not
the case. In order to address these recalcitrant adipose deposits which
are common in the upper abdomen, back, flanks, arms and legs, plastic
surgeons utilize suction-assisted lipectomy (SAL), more commonly known
as liposuction[70]. Liposuction is not for weight loss,
although as much as 6-8 liters or more of fat may be removed safely in a
single session[71]. Liposuction is used to “sculpt” areas of
the body that need further refinement in their contour. SAL, like most
procedures, is effective and safe when performed by a board certified
plastic surgeon in an appropriately monitored setting. Although SAL
alone is commonly performed as an ambulatory procedure, when more than 5
liters of lipoaspirate is removed in one session, the procedure is
considered “large volume” liposuction and overnight monitoring is
required[71]. SAL may be used concurrently with any of the
above mentioned contouring procedures, or may be used afterwards to fine
tune the results. Although not very painful, liposuction can prolong
swelling and edema when used in conjunction with other body contouring
procedures. A less frequent complication of SAL is persistent seroma.
Transient parasthesias and bruising may also occur after SAL[72].

SEQUENCE OF SURGERY

Body contouring after massive weight loss is a
significant undertaking on the part of both the surgeon and the patient.
As stated earlier, many of these patients are chronically malnourished
which predisposes them to increased surgical morbidity[21,73].
The surgery itself is laborious and sometimes involves considerable
blood loss. For these reasons, most surgeons stage the procedures[19].
Usually the abdomen and torso are treated first and, in less severe
cases, may be combined with brachioplasty, thigh lift and or breast
lift. The number of procedures performed at one time depends upon the
health of the patient and the number of surgeons available. In centers
where a “total body lift” is performed, two teams operating
simultaneously are mandatory to limit time under anesthesia, although
such procedures may still take eight or more hours[39].

As mentioned previously, special consideration must be
given to the massive weight loss patient, since they are often
relatively malnourished and even anemic secondary to their weight loss.
Although severe complications such as pulmonary embolism or even death
are relatively rare (0.02% or less)[74], minor complications
such as seroma, infection or delayed wound healing are common with some
surgeons reporting a greater than 70% total complication rate,
especially in refractory smokers[16]. However, most patients
will gladly trade these minor complications for the significant
improvements in their body contour and by direct extension, their self
image and confidence.

MOLECULAR ADVANCES IN WEIGHT LOSS

Few drugs remain approved for weight loss. The dearth of
pharmaceutical solutions is not for a lack of effort on the part of
medical researches, but rather the complex nature of obesity. Most
promising advances in weight loss technology surround the hormones
leptin and ghrelin, and the peptide known as PYY. These molecules all
help regulate mechanisms of obesity. Currently, pharmaceutical companies
are developing a variety of compounds to modulate the effects of these
compounds.

CONCLUSION

Body contouring after bariatric surgery is currently the
fastest growing field within plastic surgery[75]. At the same
time, body contouring after massive weight loss continues to evolve as
surgeons refine patient selection, technique, and improve safety.
However, the surge in weight loss-related surgeries has resulted in
ethical questions, such as who should be treated, which operation is
best, and who should be performing the surgeries. For these reasons,
national consortiums have been founded to develop consensus responses to
some of these questions. Meanwhile, though post-bariatric surgery is
associated with a greater frequency of complications than “traditional”
body contouring, the major transformation imparted by these procedures
results in a high degree of patient satisfaction.

References

1 American Obesity Association. Obesity in the U.S.
Available from: URL:
http://www.obesity.org/subs/fastfacts/obesity_US.shtml